APPLICATION FOR PERSON WITH A DISABILITY OR …

1 PERSON with a DISABILITY (K9) -Complete Sections A, B, C or D (NOT BOTH), E (if applicable), and F. FEE: $11 PERSON with a DISABILITY Motorcycle (BK) - Complete Sections A, B, C or D (NOT BOTH),E (if applicable), and F. Fee: $11 Hearing Impaired (S4) -Complete Sections A, B, C, E (if applicable), and F. FEE: $11(NOTE: No Special Parking Privileges)qqAPPLICATION FOR PERSON with A DISABILITY ORHEARING IMPAIRED REGISTRATION PLATE OR APERSON with A DISABILITY MOTORCYCLE PLATECHECK ( 4 ) TYPE OF REGISTRATION PLATE REQUESTED - See reverse side for instructions and eligibility Plates ( with identical plate numbers) for vehicles equipped with a Wheelchair/Personal Assistive Device Carrier. (See reverse for instructions)qFor two PERSON with a DISABILITY Plates (IV) - Complete Sections A, B, C or D (NOT BOTH), E (if applicable), and F.

2 FEE: $11qBCDC ertification by Police Officer - A police officer may only certify that the applicant does not have full use of a leg or both legs, or is : If Section C above is completed, please skip this Owner Name (or Full Business Name)Co-Owner NamePA DL/Photo ID# or Bus. ID#Date of BirthComplete the information to the left if you qualify as a PERSON in local parentis, parent (includingadoptive parent or foster parent), or a spouse of a PERSON who qualifies for a PERSON with DisabilityPlacard as specified in reason code 1 through 8 on the reverse side of this of PERSON with DISABILITY Relationship to Applicant Street Address City State Zip CodeHealth Care Provider s Printed NameOffice Street AddressCityState Zip CodeHealth Care Provider s SignatureMedical License Number( )Officer s Printed NameDepartment/StationCityState Zip CodeOfficer s SignatureBadge NumberTelephone Number( )

3 This is to certify that the PERSON listed above with a DISABILITY has the condition checked below and is entitled to the use and privileges of the registrationplate requested, is blind, ORdoes not have full use of a leg or both legs as evident by the use of a: crutcheswheelchairwalkercane/quad caneother prescribed deviceqqqqqqMV-145 (7-17)(state device)PA DL/Photo ID# Date of BirthVehicle Information (NOTE:In conjunction with replacement of your registration plate, you will receive one registration card. If additional registrationcards are desired, the fee is $2 for each card. Number of Duplicate Registration Cards Requested @ $2 each _____.)Vehicle Identification NumberRegistration Plate NumberTitle NumberCertification From a Health Care Provider Licensed or Certified in PA or a Contiguous State (New York, New Jersey, Delaware, Maryland, West Virginiaor Ohio).

4 THIS SECTION MUST BE COMPLETED IN FULL. For Department Use OnlyBureau of Motor Vehicles Box 68593 Harrisburg, PA 17106-8593 FIRST CHOICEThe number of allotted letters or numbers in combination varies depending on the selected registration plate type. Pre-printed letter configurations or designated letter(s)appear on personalized registration plates based on the type of plate requested. Please see the reverse side of this APPLICATION for additional information. Only onehyphen or space is permitted as part of the available spaces for personalization. No other special characters are available. Please use capital letters and print clearly. NOTE: When requesting a numeric character of zero, please show as " " instead of the alpha character "O." Since this is an electronically fillable form, after printing the form, please be sure any zero is marked with a "/.

5 "EOPTIONAL PERSONALIZATION REQUEST- NOTE: Additional Fee Required. For appropriate fees see reverse CHOICETHIRD CHOICEA pplicantInformation - List all information as shown on current registration Address City State Zip Code Notarization And Applicant Signature - Applicant, natural parent or other authorized PERSON listed in Section B must sign state that I/we have read and signed this APPLICATION after its completion, andI/we swear or affirm that the statements made herein are TRUEand CORRECT, andthat any statement made on or pursuant to this APPLICATION is subject to the penaltiesof 18 Section 4903(a)(2) (relating to false swearing), which shall includepunishment of a fine not exceeding $5,000, or to a term of imprisonment of not morethan two years, or SignatureTelephone NumberDate( )

6 SUBSCRIBED AND SWORNTO BEFORE ME: MONTH DAY YEARSIGNATURE OF PERSON ADMINISTERING OATHSTAMPSIGN IN PRESENCE OF NOTARYFA pplicant SignatureTelephone NumberDate( )This is to certify that _____ (Name of PERSON with DISABILITY )is under my care and has a hearing impairment, orhas the following condition listed on the reverse side of this APPLICATION under Eligibility Requirements : _____ (List Reason Code #1-8.)NOTE: If reason code #4 is listed above, please indicate the type of device used: :Only those conditions listed on the reverse side of this APPLICATION qualify an applicant for a PERSON with a DISABILITY registration TypePerson with aDisability RegistrationPlateEligibility Requirements Reason Codes Applicant:(1) is blind.(2) does not have full use of an arm or both arms.

7 (3) cannot walk 200 feet without stopping to rest.(4) cannot walk without the use of, or assistance from,a brace, cane, crutch, another PERSON , prostheticdevice, wheelchair or other assistive device.(5) is restricted by lung disease to such an extentthat the PERSON s forced (respiratory) expiratoryvolume for one second, when measured byspirometry, is less than one liter or the arterialoxygen tension is less than 60 MM/HG on roomair at rest.(6) uses portable oxygen.(7) has a cardiac condition to the extent that theperson s functional limitations are classified inseverity as Class III or Class IV according to thestandards set by the American HeartAssociation.(8) is severely limited in his or her ability to walk dueto an arthritic, neurological or orthopedic condition.

8 (9) is a PERSON in loco parentis of a PERSON specifiedin paragraph (1), (2), (3), (4), (5), (6), (7) or (8)above.(10) is the parent, including adoptive parent or fosterparent, of a child or adult child provided that theperson has custody, care or control of the childor adult child and the child or adult child satisfiesparagraph (1), (2), (3), (4), (5), (6), (7) or (8);OR,(11) is the spouse of a PERSON specified in paragraph(1), (2), (3), (4), (5), (6), (7) or (8).Any PERSON with a hearing impairment verified by a licensed health care disabilities as listed for PERSON with aDisability registration Vehicles(1) A passenger vehicle or truck with aregistered gross weight of not morethan 14,000 lbs. The vehicle must beused by a PERSON with DISABILITY oroperated exclusively for the use andbenefit of the PERSON with a :Organizations that operate apassenger vehicle to transport personswith disabilities must supply PennDOTwith the following: a) A notarized statement of howthe vehicle will be used and thetype of services that will beprovided.

9 B) The weekly or monthly numberof hours that the services :The vehicle(s) must be titled inthe name of the special as above for Personwith a DISABILITY of PERSON in Loco Parentis- ANY ADULT charged by law with the natural parent s rights, duties and responsibilities acting on behalf of a minor child (under 18) in place of the child s natural parents. A Health Care Provider is defined as a physician, chiropractor, podiatrist, physician s assistant or a certified registered nurse practitioner. A Health Care Provider may only certify disabilities within their scope of practice. This APPLICATION may only be used by a vehicle owner or co-owner who qualifies for the type of registration plate indicated on the front of this APPLICATION unless the vehicle owner is a PERSON in loco parentis, parent of an adult child, or a spouse of a qualified PERSON .

10 NOTE:Individuals should list their PA Driver s License (PA DL) or Photo ID# in the space provided. Businesses should list their Business ID# (Bus. ID) where indicated ( ). Only one registration plate issued per qualified PERSON for one vehicle. Should you desire to renew your registration in conjunction with this APPLICATION , you must complete Form MV-140, "Request for Registration," or your registration renewal APPLICATION and return it with this APPLICATION along with your registration fee and the $11 replacement registration plate fee (if applicable). You may be eligible to renew your vehicle for either a one-year or two-year registration period. Both registration periods and the required fees are provided on the registration renewal form or Form MV-70S, Bureau of Motor Vehicles Schedule of Fees.